Systems approach can improve intimate-partner violence screening

Sara Berg
Senior Staff Writer
AMA Wire
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About one in four women and one in seven men in the United States experience intimate partner violence (IPV) in their lifetime, according to a 2015 article published in the journal Science. IPV is a serious and preventable public health problem that affects millions of Americans, according to the Centers for Disease Control and Prevention (CDC). Yet physicians often struggle with how to initiate difficult conversations about this topic and provide proper screening and intervention for IPV.

IPV screening and counseling are rated as a “B”-level recommendation for women of childbearing age by the U.S. Preventive Services Task Force. The recommendation states that physicians should “screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services.” It applies to women who do not exhibit signs or symptoms of abuse.

However, physician training by itself is not enough. Improving inquiry, intervention and referral in health care settings requires a systems level approach, according to the authors of a 2016 opinion essay published in JAMA that outlines the improvements that Kaiser Permanente has made to IPV prevention and response.

Physicians can make use of new toolkits and webinars offered by the nonprofit Futures Without Violence (FWV), as well as a clinical tools offered in Epic. When used together, these new tools can help physicians and their teams successfully screen for IPV and provide services for patients.

The new tools “provide a template for implementing routine screening for the patients that are being evaluated,” Mary Anne McCaffree, MD, told AMA Wire®in an interview. Dr. McCaffree is a pediatrician and specialist in neonatal-perinatal medicine from Oklahoma City. She is chair of the National Health Collaborative on Violence and Abuse and served on the AMA Board of Trustees for the AMA from 2008–2016.

“The physicians and staff can identify the patient’s previous trauma experience and refer to resources such as mental health, group therapy and shelters that already exist,” she said. “The key is asking each patient and providing assistance at the office visit, with resources that already exist in the community.” Too often, Dr. McCaffree said, physicians and their staff are unaware of the resources that are available to help patients who have experienced IPV.

A link to chronic disease

“One of the things that is really compelling to health care organizations is the research that highlights both the acute and long-term impact on both medical and mental health conditions and health care utilization,” said Brigid McCaw, MD, medical director for the Northern California Family Violence Prevention Program for Kaiser Permanente. She co-wrote the JAMA essay referenced earlier.

While most physicians are aware of injury occurring with IPV, some may not be aware of the CDC data about the increased risk of stroke, asthma, heart disease, diabetes and other chronic conditions, Dr. McCaw added.

Other physical and mental-health problems associated with IPV include: cardiovascular disease, hypertension and stroke; chronic pain; depression, anxiety, PTSD and other mental illness; drug and alcohol abuse.

“One of the ways to improve health outcomes, decrease the very high rates of obesity, hypertension, depression, poor education outcomes and chronic disease is to implement domestic-violence screening,” said Dr. McCaffree.

Knowing why to pursue this screening and knowing how best to do it are, of course, two separate questions.

“Part of the how is making sure we have the tools that support clinicians in how to ask,  , how to respond and how to address this so it becomes just like the other things we are comfortable doing within health care such as measuring blood pressure, cholesterol, and asking about smoking and exercise,” said Dr. McCaw.

Making a difficult conversation routine

“Kaiser Permanente uses a system-wide approach that includes physician training, patient education materials, community linkages and clinical resources including tools in the electronic health record (EHR),” said Dr. McCaw.

The use of the Epic electronic health record (EHR) screening, documentation, and referral tools and the toolkits from FWV are individual pieces to the solution.

“Many providers are addressing violence, but we also know we have a long way to go for creating a real change in the standard of care,” said Lisa James, who runs the National Health Resource Center on Domestic Violence and directs Futures Without Violence. “There are a lot of health systems and individual providers moving in this direction, but not nearly enough. So I am very pleased that the Epic tools are out there to help providers support patients health and safety.”

In addition to Epic’s integrated screening tools, FWV encourages physicians to provide universal education messages and focus on what to say if a patient says they have experience intimate partner violence.

“These are things that can help physicians do their job better so that, ultimately, addressing and preventing IPV becomes part of their everyday practice like other important health conditions,” Dr. McCaw said.

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Oct 17, 2017
The ongoing drinking water contamination in Flint, Michigan, serves as a wake-up call to physicians about their public health duties during such crises.